ExchangeCoverageHigh impact
Effective September 1, 2026: Pharmacy and Biopharmacy Policies
Ambetter·MS · Pharmacy·Pharmacy
Effective date
Sep 1, 2026
We identified it
Aug 26, 2026
Summary
Magnolia Health Plan has updated pharmacy and biopharmacy policies effective September 1, 2026, with changes to medical necessity review criteria. The specific policy details are contained in a PDF document (HIM Criteria Summary Table) that must be reviewed to identify which drugs, biologics, or services are affected by new or modified coverage rules.
Action Required
By August 31, 2026: Billing and clinical teams must download and review the HIM Criteria Summary Table PDF from Ambetter from Magnolia Health's Clinical & Payment Policies webpage to identify all pharmacy and biopharmacy policy changes. Update billing system rules, prior authorization workflows, and clinical staff guidance to reflect new medical necessity criteria. Ensure all pharmacy claim submissions after September 1, 2026 comply with updated policies. Contact Magnolia's Pharmacy Department at 1-866-912-6285, ext. 66409 with questions. Failure to implement changes by the effective date may result in claim denials for non-compliant submissions.